Imagine a patient walks into your office with type 2 diabetes mellitus and low motivation for management. He is a 50-year-old white male who suffers from depression and has a body mass index (BMI) of 30. What is your first step?
Ask any large group of providers, and one may receive a smorgasbord of answers. The next move in such a scenario can vary due to philosophy or simply a different sequence of care, yet some treatment choices are inevitably more effective than others. Unlike a broken bone or an infection, there are few, if any, universal fixes. Each patient brings a different set of variables to the table. To reduce any deficits of care that a clinician may have, a new generation of patient simulators has emerged to hone the modus operandi for patients with diabetes.
Software programs such as SiMCare Diabetes and the American Diabetes Association (ADA) Simulation Case Program take metadata about patient treatment plans and outcomes and distill them into a user interface almost like a video game that allows practitioners to run through unique patient cases. Because endocrine experts face complex diseases that often involve solutions akin to a Rubik’s cube, practice on virtual patients may make treatment plans easier to figure out. Program designers hope that their software will allow medical students and clinicians to gain the experience of hundreds of patient interactions and outcomes in a risk-free virtual environment.
Patterns of Failure
Patrick J. O’Connor, MD, MPH, the senior clinical investigator at HealthPartners Institute for Education and Research, which owns SiMCare, helped develop the original version of the company’s patient simulator for diabetes with support from National Institutes of Health (NIH) grants before patenting it as a product. He is also a primary care physician and chronic disease epidemiologist. He says that the eight or nine main factors that a physician must consider for each case of diabetes often create room for error. “We mapped the decision space, and we found that doctors have many different patterns of failure,” he says.
He and his colleagues profiled providers across 22 domains of diabetes care, from depression to drug prescriptions, in a study of the simulated learning program’s effectiveness. A library of 600 learning cases were compiled, and they then assigned about a dozen to each provider that best matched their weak points. Physicians had six months of simulated time to reach desired outcomes, receiving performance feedback along the way.
The entire process took about three hours per doctor, and they were asked to keep trying at each learning case until attaining treatment goals. The results of the participating physicians’ real-life patients were compared to a control group of patients treated by providers that did not use the simulated patient program. Over the next year and a half, the patients treated by doctors who used the software had better diabetes control than those who did not — a difference of about ³⁄ ¹0 of 1 percent of HgA1C. Though small, the effects were clinically significant, and the journalDiabetes Care published the full study.
Filling a Gap
Such technology helps solve another growing problem: the shortage of expert physicians to train students and colleagues. Doctors can spend more time treating real patients and less time teaching others if virtual trainers are found to be effective. O’Connor conducted a second study among primary care residents to see how the technology fared as a teacher. “We found major improvements in their knowledge of diabetes and ability to manage cases with this simulated intervention.” The research included 19 residency programs and also used a randomized control group for comparison.
The same type of software could be used for patient education as well — informing patients about their best treatment options and how their diet and other health behaviors may result in varying outcomes. E-learning modules can already be found through some organizations, like the Children’s Hospital of Philadelphia and its online courses on different patient concerns, like Taking Care of Ketones and Alcohol & Diabetes. However, these examples lack the cause and effect function of decisions made by the user in a virtual program. The videogame-like reality of simulated patients seems to play an important role in the effectiveness of theses tools.
A study published in the Journal of Medical Internet Research used the virtual world Second Life to execute continuing medical education (CME) for diabetes. Test cases showed the percent of the participating physicians providing a correct insulin initiation plan increased from 60% (6 of 10) before the program to 90% (9 of 10) afterward, and the amount of participants providing correct initiation of mealtime insulin increased from 40% before to 80% after. Every single participant agreed that the Second Life intervention was effective for diabetes education.
These results bode well for the use of highly interactive simulators for teaching both providers and patients about the treatment of diabetes and other diseases. A company called SciMed launched what is perhaps the closest program to Second Life for diabetes, called the Virtual Diabetes Institute. The institute offers numerous different CME courses that immerse the user in a simulated world comprised of a two-story educational center that contains a library, courtyard, and other features for physicians to use and collaborate within.
More recently, a study published in the Journal of Diabetes Science & Technology required patients to watch a 15-minute video each week of an avatar with their physical characteristics, like weight and skin color, performing healthy behaviors such as walking on a treadmill that led to weight-loss. In theory, the virtual reality helped participants actualize diet and exercise habits. They lost 3.5 lbs. over the course of four weeks on average.
Patient simulators have, of course, been used for ages in the form of mannequins, but digital learning programs may be better suited for nuanced diseases like diabetes. Such programs can often be operated from one’s iPad at home or a computer in the office, making education more convenient and efficient. But the largest benefit may be the engaging platform of virtual reality. When learning feels like a game, patients and providers alike seem to be tuned into treatment.
— Mapes is a freelance writer in Washington, D.C., and a regular contributor to Endocrine News.
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